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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609631
Report Date: 07/16/2024
Date Signed: 07/16/2024 02:07:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240712160413
FACILITY NAME:GOLDEN HILLS RETIREMENT CTR INCFACILITY NUMBER:
197609631
ADMINISTRATOR:GUEVARA, ITZELFACILITY TYPE:
740
ADDRESS:10159 HILLHAVEN AVETELEPHONE:
(818) 352-1559
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:60CENSUS: 36DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Adriana Cisneros - Assistant AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure that resident's needs were met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Assistant Administrator Adriana Cisneros and explained the reason for the visit.

LPA conducted physical plant tour at 9:23 AM, requested copies of facility documents relevant to the investigation at 9:54 AM, reviewed records from 10:00 AM to 11:15 AM and interviewed staff, residents, and witness between 11:30 AM to 1:10 PM. It was alleged that Staff doesn't come when needed and R1's wheelchair is broken and not being replaced. LPA's record review today revealed that R1 is a client of Frank D Lanterman Regional Center (FDLRC) since 2012. Further review also revealed that R1 is being provided a 1:1 care staff by the Regional Center for five (5) hours every day five (5) days a week. LPA's interview with R1 today at 11:30 AM revealed that R1 was aware that it was the responsibility of and following up with FLDRC for the replacement of R1's wheelchair. LPA's interview with FDLRC's staff confirmed that R1's wheelchair is FLDRC's responsibility and has been working for the replacement since it was broken.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20240712160413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOLDEN HILLS RETIREMENT CTR INC
FACILITY NUMBER: 197609631
VISIT DATE: 07/16/2024
NARRATIVE
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(continued from LIC 9099)

LPA's interview with the Assistant Administrator today at 12:13 PM revealed that the facility has a spare wheelchair in stock and willing to give it to R1 if R1 agreed. R1 agreed to have the replacement today offered by the Assistant Administrator. Further interview with R1 also revealed that staff always come when needed as it has been for long time. LPA's interview with additional four (4) residents or more than 10% of the current census also revealed that four (4) out of four (4) residents interviewed stated that staff always come when needed within reasonable time (5-15 minutes).

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2